COVID-19 vaccination strategy update June 2021

At the time of publication of this refreshed vaccination strategy, Wales is leading the world in terms of numbers of people vaccinated in a country of more than a million people. This is a remarkable achievement and I would like to pay tribute to all of the people who have worked so hard over so many months giving significant protection to the people of Wales against COVID-19. I would also like to thank the public in Wales for coming forward in such huge numbers to receive their vaccinations. They are not only keeping themselves safe, but they are keeping their loved ones safe and others in the community.

By 7 June more than 2.1 million people in Wales have now had their first dose of the vaccine and more than 1 million people were fully vaccinated, having received both doses of the vaccine. The second dose is essential for longer term protection so it is really important that second dose offers are taken up.

As we move closer to having offered a vaccine to the entire adult population of Wales, it is timely to update the COVID-19 Vaccination Strategy for Wales which we first published on 11 January. To ensure the people of Wales are kept informed, we published updates to the strategy on 26 February and 23 March. Today I am publishing a further update – a reflection of the pace and progress of our programme.

Phase 2 of our programme is well underway. We said that by the end of July we will have offered a first dose of the vaccine to all eligible adults in Wales and I am confident we will hit this important milestone shortly. 

I am extremely proud of our Health Board vaccination teams, local partners and the many volunteers across the country for their unwavering commitment, and I want to thank them for making our incredible progress possible. Our programme in Wales has been ranked one of the best in the world. The continued support of the Welsh public has not gone unnoticed; you are all helping to keep yourself, your family and friends safe.

The Wales Programme continues to ensure the right vaccines are given at the right time to the right people in accordance with Joint Committee on Vaccination and Immunisation (JCVI) guidance. With the recent emergence of a variant of concern with the potential to become a dominant UK strain causing COVID-19, we have been reminded once more just how quickly the virus can change and put pressure on our plans.

There is still a risk of a third wave with increased transmission and the hospitalisations that accompany increased prevalence within our communities. Vaccinations will help to limit the spread of the virus. We will also remain vigilant in terms of other new variants that could emerge which could evade the protection of current vaccines. We will be ready to adapt our plan and continue to engage with the UK government to ensure that the vaccines procured and supplied are the most effective against potential variants. We will not be entirely safe until more people around the world have received protection from COVID-19.

It is always important to continue to follow the rules and guidance on hygiene, social distancing and face coverings in place to keep ourselves and our families safe. That way we have a better chance of being able to continue to live with reduced restrictions as we move into the summer.

I want to thank the people of Wales for their continued support. I believe the vaccination provides a huge contribution in tackling COVID-19, and provides strong hope for a brighter future.

Eluned Morgan
Minister for Health and Social Services

Since publishing the second update to the COVID-19 Vaccine Strategy for Wales in March, our Wales programme has continued to be successful. We have been administering first doses at a faster pace than any other UK nation for several weeks. We have offered a first dose of vaccine to all those in priority groups 1 to 9, hitting our Milestone ahead of the mid-April deadline.

Our NHS organisations, and the amazing staff within it, have been able to flex and adapt to fluctuations in Vaccine supply and to the needs of the public. 

Where are we now?

Since 4 June 2021 we had:

• 85% of adults in Wales have received their first vaccine
• 2 million first doses
• 58% of 18 to 19 year olds in Wales have received their first vaccine
• 45% of adults in Wales are fully vaccinated

The Wales COVID-19 Vaccination Programme is being considered amongst the most effective and efficient in the world. There are a number of factors that contributed to our success.

Ensuring the time between receipt and deployment of the vaccines is kept as short as possible. Every dose of vaccine delivered to Wales is moved quickly to our vaccination centres, GP practices and pharmacies to be given to citizens straight away.

Taking great care to keep waste to a minimum. In spite of the storage, distribution and preparation challenges posed by the vaccines, we have kept waste incredibly low. We do not want to waste a drop of these life saving vaccines.

Tracking every dose of vaccine from delivery to arm. The Welsh Immunisation System (WIS) gives us end to end visibility of every vial of vaccine, this ensures we don’t have large amounts of vaccine lying unused in any part of our delivery system.

Flexing our infrastructure and capacity to manage planned dips in supplies. There will be weeks where the amount of vaccine available to us are low but we expect and plan for them. This means our programme has run at a consistent pace over many months.

Planning ahead, anticipating changes in supply or capacity and making good choices at key points i.e. beginning our second dose phase of Pfizer in February.

Capitalising on the benefits of our integrated NHS structures where our seven Health Boards cover everything from public health and primary and community care to secondary and tertiary services, including taking responsibility for planning and delivery care for their resident population.

Moving through priority cohorts swiftly, at the right time. We decided early on that health boards would be able to offer appointments to the next priority cohort once 50% of the priority cohort above it had been vaccinated. This practical decision helped ensure we kept waste at a minimum and our clinic lists stayed full so that we moved efficiently through the vaccination programme.

Responding quickly to changes in demand. Health boards operate their own reserve lists and short notice lists and can use their operational flexibility to ensure no vaccine is wasted, particularly if the vaccine has a short shelf life or when people cancel or cannot make an appointment at short notice.

Responding to emerging risks. The operational flexibility has allowed us to respond quickly to the JCVI’s advice on the so-called India variant (VOC B.1.617.02). Health boards are able to bring forward second doses in certain areas, should this be a clinical priority, where supply allows.

Understanding local needs. Deployment models vary by health board, normally based on geography and population density. Mass vaccination sites are being used in areas of higher population, but in rural and hard to reach areas some Health Boards have adopted smaller local site models which enable vaccines to be delivered closer to communities. The demography of some Health Boards has meant they have used more Primary Care including GPs and community pharmacies than others.

Getting vaccine to those who are most vulnerable or under-served often previously known as ‘harder to reach’. Health boards are using outreach models to vaccinate in care homes and have set up temporary and mobile hubs in under-served communities and rural areas.

Regularly telling the people of Wales how we are doing. The Welsh Government, Public Health Wales and Health Boards publish daily updates of the number of people vaccinated. We also publish a weekly progress update and weekly data on deliveries and waste.

The dedication and resilience of the NHS staff and support staff who have adapted and flexed under enormous pressure to set up a range of vaccination models which make best use of the vaccines available, whilst also providing opportunities to deliver vaccines close to the communities they serve has been inspirational.​

We have been offering vaccinations in line with advice from the UK’s independent expert Joint Committee on Vaccination and Immunisation (JCVI). The same priority list, by age and risk, is being followed by all four nations in the UK and has the support of all four Chief Medical Officers within the UK. Groups 1 to 9 are in phase 1, and groups 10 to 12 are in phase 2.

1. Residents in a care home for older adults and their carers
2. All those 80 years of age and over and frontline health and social care workers
3. All those 75 years of age and over
4. All those 70 years of age and over and clinically extremely vulnerable individuals
5. All those 65 years of age and over
6. All individuals aged 16 years to 64 years with underlying health conditions which put them at higher risk of serious disease and mortality
7. All those 60 years of age and over
8. All those 55 years of age and over
9. All those 50 years of age and over
10. All those aged 40 to 49 years
11. All those aged 30 to 39 years
12. All those aged 18 to 29 years

We have based the 3 milestones in our strategy on this prioritisation.

Phase 1

Milestone 1: to have offered all adults in groups 1 to 4 a vaccine by mid-February (achieved 12 February 2021). 

These are our most vulnerable groups who would have the worst outcomes from catching the virus, along with care home staff and front line health and social care workers. It was vitally important that we work to vaccinate these people first to keep them safe. Uptake of the vaccine amongst these groups have been exceptionally high with at least 91% in each group taking up their offer of a vaccination.

Milestone 2: to have offered all adults in groups 5 to 9 a vaccine by mid-April (achieved on 4 April 2021). 

These groups were the next vulnerable groups, in order. Cohort 6 included people down to the age of 16 with certain health conditions and were at most risk. By targeting the priority groups in Milestones 1 and 2, it is estimated that around 99% of deaths from COVID-19 have been prevented.

Phase 2

Milestone 3: to have offered a first dose of the vaccine to those in group 10 i.e. the rest of the eligible adult population by the end of July. Our aim, as with groups 1 to 9 is to achieve at least 75% uptake.

Milestone 3 represents Phase 2 of our programme and where we are now. Our target group is a younger and healthier population who will likely feel less at risk and potentially also have increased hesitancy. Therefore our communications have been targeted and evidence based and will make full use of public and trusted figures to maintain support and motivation for vaccination.

With the strong progress we have seen so far in our vaccination teams, subject to supply, we expect to achieve the following during Phase 2:

• 2 million first doses – this was achieved on 16 May
• 1 million second doses – this was achieved on 23 May
• Reach 75% first dose take up in each of the 10 age groups by end of July

Over the last few months we have seen NHS Wales administer thousands of vaccines; a mix of first doses and second doses and of different vaccines running alongside each other. This means that the NHS is effectively operating different sets of arrangements which brings challenges around vaccine stock management and capacity.

Every dose administered and every person protected really does make a difference. We want to maintain the current high levels of vaccine uptake to keep Wales safe. As take up of the first dose of vaccine for cohorts 1 to 4 has reached over 90% for each cohort, we also want to achieve this high level of take up of the second dose. The second dose is essential for full and longer term protection, including against variants, so it’s really important that second dose offers are taken up.

During this Phase, the programme has had to adapt to JCVI advice in addition to the new Delta variant of concern first identified in India.

In response to the JCVI advice, we prioritised the vaccination for household contacts of adults who are immunosuppressed. This was to protect those adults who have weaker immune systems and are more likely to have poorer outcomes if they get COVID-19. 

Working with national caring organisations, we brought clarity to the arrangements for unpaid carers in cohort 6 by introducing guidance and an online application for those not registered with their GP. 

We have published COVID-19 vaccination guidance for pregnant women, those breastfeeding and women of childbearing age, helping them to make an informed choice about taking up the vaccine, in accordance with JCVI guidance on recommended vaccines.

We have also seen changes to precautionary safety advice for the younger age range below 40 years. We were able to support the NHS to respond quickly to those changes and have ensured that the appropriate vaccine is available at the right time for individuals. We also ensured the public had the information they needed to make an informed choice, which we found to be critical to uptake.

As long as supply allows, and with the continued support of the NHS, we are confident we will meet Milestone 3 earlier than our ‘End of July’ target. We are expecting to have offered a vaccination to all those over 18 early next week and we are expecting to have achieved over 75% take up in each group a month early. This will bring Phase 2 to and end and move us forward to Phase 3.

Whilst the uptake of the COVID-19 vaccine in Wales remains extremely high, there are still a number of people across all age ranges who, despite receiving more than one offer, remain unvaccinated.

We operate a ‘No one left behind’ principle and have always looped back to ensure any who have been missed out are re-contacted and offered another appointment. It is never too late to accept the offer of the vaccine.

Every person must be given fair access to vaccination with equal opportunity to receive their vaccination. Every effort must be made to remove barriers. That is why additional and tailored support and reasonable adjustments for those with special requirements, under-served groups and those hard to reach individuals have and will continue to be put in place.

Over the last month we have seen an increase in non-attendance rates across Wales. With new variants appearing which have increased transmissibility, it is as important as ever to take up the offer of a first, and crucially, a second vaccination. The science is telling us that second doses provide much higher protection

Why are some people not taking up their offer of vaccinations?

By understanding who is not taking up their offer and why, we can take action to remove barriers. This could be due to transport issues, being unable to reschedule appointments easily, responsibilities such as child care and out-of-pocket expenses incurred, incorrect patient contact details, access and logistical issues, in addition to lack of confidence and trust in the vaccination.

Learning from other vaccination programmes and research we know there are some groups of people who are, for various reasons, less likely to take up their offer of a COVID-19 vaccine. For example men have lower uptake of preventative interventions than women.

Other groups who may have particular difficulties include:

• people experiencing homelessness, substance misuse or severe mental illness
• people experiencing sensory, physical or learning disabilities
• asylum seekers, refugees and migrants
• people from minority ethnic groups
• people at economic disadvantage
• single parents with dependent children

Public Health Wales provides a monthly report on equality in coverage of COVID-19 vaccination in Wales by sex, socioeconomic deprivation and ethnic group. The findings in the most recent report (covering 8 Dec 2020 to 14 May 2021) are:

• inequality gaps in coverage of at least one dose of COVID-19 vaccine between individuals from ethnic minorities and socioeconomic deprivation groups in adults in Wales have narrowed steadily since March. However significant inequalities in coverage remain especially in individuals with Black African and Black Caribbean heritage.
• narrowing of inequalities highlights the importance of offering opportunities to catch up and instigating local and national public health interventions
• the largest inequality in coverage was seen between ethnic groups in adults aged 50 to 59 years. First dose coverage for the combined Black, Asian, Mixed and Other ethnic groups in this age group was 79.9% compared to 91.3% in the combined White ethnic groups.
• vaccination coverage was therefore lower in groups who are at increased risk of COVID-19.
• a similar pattern of inequality is seen in coverage of the second dose as for the first, although the gap in coverage is usually wider and this phase of the vaccination programme is less mature.

What action are we taking?

Ensuring equitable uptake is a significant strand of work within the COVID-19 Vaccine Programme and the Wales COVID-19 Vaccination Equity Strategy (published March 2021) sets out the programmes intentions. There are two approaches we are taking to understand the issue of uptake and to put action in place.

Vaccine Equity Committee

The Committee was established to provide oversight and review of vaccine equity within the COVID-19 vaccination programme. It brings together representatives from umbrella groups, the under-served groups themselves, and third sector organisations, as well as experts from PHW and the NHS to understand barriers to COVID-19 vaccination for marginalised groups, and work to remove them. Committee members bring their expertise to make recommendations and suggestions as to what would encourage and enable these groups to take up their vaccine. Some of the recommendations are for government, some for the NHS and Health Boards, and some they will take forward themselves. 

DNA (did not attend) working group

Offers of vaccinations appointments are automatically scheduled and sent in a letter to a person’s home. If they do not attend, and don’t let the vaccinators know, they are considered a DNA. The NHS continues to review data on who doesn’t attend their appointment to understand temporal and geographical patterns through the DNA working group. This allows local or national strategies such as re-balancing of auto-scheduled appointment to support effective operational delivery and targeted communications to inform and enable people to take up their offer. As a result they have flexed and put in place specific arrangements for some marginalised groups, including those experiencing homelessness or caring for others.

If we pull the action strands together, they can be clustered under the following 4 headings outlined in the vaccine equity strategy:

1. Strategy and Action plan

• vaccine equity committee: oversight and review of inequities
• subgroups of VEC: physical, sensory and learning disabilities, homelessness, severe mental illness and substance misuse, asylum seekers and refugees, minority ethnic groups, economic disadvantage
• shared learning space for examples of good practice across health boards
• equality health impact assessment
• encourage GP registration and ensure details are correct, data cleansing

2. Access and delivery models

• DNA groups, understand patterns and consider targeted approach
• offering alternative to auto-scheduled appointments
• making reasonable adjustments
• flexibility of delivery model
• flexibility of booking system

3. Surveillance data and research

• monthly enhanced surveillance report
• attitudinal survey: PHW/YouGov
• behavioural science informed follow up of DNAs
• qualitative insights gathering on vaccine hesitancy

4. Communication and engagement

• engagement group
• shared asset bank of comms for local use
• community champions
• trusted voices
• role of umbrella bodies and charities

Once we have achieved milestone 3, there will be a specific period of focus on equality of coverage with more flex and outreach.

The following shows examples of recommendations from the Vaccine Equity Committee to take this forward. Health boards are already taking forward some of these and we continue to work with them to review the data, and use it to inform national and local planning, delivery and communications. 

Understand vaccine coverage in under-served groups

• Development of local data for health boards to identify areas of low vaccination coverage and appropriately target action.

Improved accessibility

• ensuring accessibility standards and reasonable adjustments are in place such as quiet places and clear access routes 
• promotion of accessible formats of information including alternative languages 
• development of GP access cards to support vulnerable groups including asylum seekers and migrants to register with GP 
• use of community transport volunteers 
• promotion of sight and hearing loss awareness training
• promotion of Health Board contact information and clear processes to follow to make appointment

Improved availability

Flexible delivery models with:

• pop-up clinics in community centres: e.g. ABUHB undertook weekend pop-up clinic in Newport city centre for over-40’s with system to take under 40’s to Newport MVC for Pfizer vaccination
• pop-up clinics in faith centres: e.g. Cardiff and Vale UHB undertaking regular vaccination centres in Cardiff mosques 
• outreach vaccination clinics for traveller communities e.g. Hywel Dda UHB, C and V UHB, ABUHB and BCUHB offering vaccination at traveller sites with Powys working with Powys CC and traveller groups to offer vaccination
• outreach vaccination clinics at point of contact for homeless people e.g. vaccination clinics at hostels and supported accommodation such as through the outreach ‘Immbulance’ in Swansea Bay UHB

Increase confidence and trust within the vaccination programme

• targeted and tailored approach for different eligible groups such as young people through social media campaign
• script for reoffering of appointment and text messages based on behavioural insights 
• making sure that migrant communities know that personal data is not shared outside the COVID-19 vaccination programme
• using trusted voices and community champions to promote key messages – this has been supported by new community and engagement officers placed within each health board to work with local communities to support the vaccination programme

As we have learnt more about the virus, its variants and how effective the vaccines are, it has become clearer that managing the virus is likely to be a long term challenge.

We will continue to carefully monitor growth of any variants in Wales. Our best route out of this pandemic remains vaccination. In line with the latest JCVI advice, we are working with our local incident teams and health boards to facilitate bringing forward, subject to Health Board available supply, second doses of vaccine targeted at people most at risk from COVID-19, where there are concerns about transmission in areas of poor vaccine uptake. Completion of the two dose course is especially important for the best protection against existing and new variant strains of the virus.

It is clear that when the virus causing COVID-19 spreads rapidly, variants may emerge that may be easier to transmit and may cause harms if they can evade our current vaccines. The Delta variant first identified in India has replaced the previous dominant variant first identified in Kent, in England and will become more widespread.

A recent study by Public Health England suggests that one dose of any vaccine protects us moderately at over 30%, but that a full course of 2 doses is required to achieve optimal protection. Two doses of Pfizer are thought to give over 80% protection and two doses of AstraZeneca vaccine are thought to give 60 to 70% protection, however one dose of each of these vaccines may only give just over 33% protection, so it is important that everyone accepts the offer of a second dose when called in line with the cohort order of risk set out by JCVI for the programme.

It is important also to follow current guidance Welsh Government guidance particularly on self isolation and testing, and on levels of indoor mixing whilst keeping good ventilation, as well as remembering to stay safe by maintaining social distance, wearing face coverings and maintaining good hand hygiene.

As we move nearer to completing Phase 2 and achieve milestone 3, where all eligible adults have been offered a first dose, what’s next?

We are working in real time to plan ahead into Phase 3 despite there being a number of things we still don’t know for certain. There are trials and studies begin conducted around the world to understand more about:

• How long people are protected for once they have had both doses of a vaccine?
• Who will need a booster and which vaccines are best for them?
• Can the flu and COVID-19 vaccination be given at the same time?
• Should young people or children below 18 years be vaccinated, and from what age?
• How we may need to adjust vaccines to respond to new variants.

The JCVI will be considering all the evidence and providing advice on the way forward in Phase 3. In the meantime, we are planning on the assumption that, to maintain immunity, four areas of focus will be needed for the next phase:

Phase 3

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The Wales COVID-19 Vaccination Programme will need to be delivered alongside other important Vaccination programmes such as Influenza and catch up school-aged immunisation programmes as we progress into the Autumn period of 2021. We will be working closely with our Health Boards going forwards on these aspects.

Booster vaccine

It is likely that those in priority groups 1 to 4 and possibly cohorts 1 to 9 or wider will need a single dose of COVID-19 vaccine as a booster vaccinations. We are planning so that NHS Wales will be ready to deliver this booster as soon as the final advice from JCVI is confirmed, setting out who to vaccinate and in what order. We expect to receive interim advice over the summer. Other cohorts may be offered also, pending advice.

Second dose

The younger cohorts, who are being vaccinated later in phase 2 will need to have their second vaccination during phase 3. 

Our aim is for everybody who has had a first dose to also take up their second dose, across all the age ranges. Subject to vaccine supply, JCVI advice and any changes to intervals between doses we are confident the delivery of second doses will continue to be as swift and successful as first doses. Health boards have local discretion and flexibility to interpret the guidance, based on what would work operationally locally or hyper-locally, which includes brining forward second doses, in certain areas, should this be a clinical priority, and where supply allows.

Subject to vaccine supply, we expect to offer everyone who is eligible a first dose by mid June and for all those that come forward for vaccination, to be offered a second dose by the end of September. 

Re-offering first dose

It is never too late to have the vaccine. As set out earlier, we will be taking forward targeted action to tackle the barriers which are stopping some people from taking up their offer of a vaccine. The Vaccine Programme has made a clear commitment to ensuring equity of opportunity and access for all.

Priority will be given at the beginning of Phase 3 to reach out into communities with a concerted and visible joint effort to enable anyone who hasn’t as yet had a jab to take up their offer of a vaccine.

Vaccinating young people

The MHRA has reviewed clinical trial data in children aged 12 to 15 years. It has concluded that the Pfizer/BioNTech COVID-19 vaccine meets the high standards of safety, effectiveness and quality required and has authorised its use for young people aged 12 to 15.

The JCVI is currently considering the clinical evidence to determine whether young people above the age of 12 should be vaccinated or whether vaccination is best offered to certain groups of children, determined by their age or clinical risk factors. No decision has yet been made and we expect the JCVI to provide this advice towards the end of July. For the purposes of planning Phase 3, we are actively considering how NHS Wales can promptly operationalise any JCVI recommendation for this age range.

Online booking system

Our current COVID-19 vaccine booking system has proved hugely successful in maintaining the pace of our vaccination programme. To underpin Phase 3, and to ensure the continued success of our effective vaccine rollout programme, we plan to launch a new online booking system. This will build on the experience of current approach but enable the public to amend their appointment if necessary and book their own vaccine appointments. This aims to meet current and future needs for the vaccine programme.

We are currently in the development phase of this work, but aim to have a digital system online to help schedule boosters, if required, by the Autumn.

We will be able to report more on these areas through our weekly narrative which provides updates and sets out progress against our strategy.

We will also continue to publish information frequently about the vaccine programme.

Public Health Wales publishes daily and weekly surveillance data, which provides information on how many vaccinations have been administered, including daily breakdowns by priority groups, and weekly breakdowns by health board. Monthly surveillance reports on equity of coverage between ethnic groups and level of socioeconomic deprivation are also now being published.

Welsh Government statisticians are publishing some of the more operational statistics attached to the programme each week, including vaccination supplies and waste.